Changes in the Practice of Psychiatry Since World War II

In assessing the psychiatric workforce today, we must address a number of distinct issues. The easiest is to determine is how many psychiatrists are in practice. More difficult is to assess how practicing psychiatrists conceptualize their clinical work.  

The foundation of each psychiatrist’s practice is formed while they are residents. We are guided throughout our careers in our clinical work by the initial philosophic principles which served as the basis for our residency’s educational program and philosophy of patient care.

Since the end of World War II, American psychiatry has undergone a member of major shifts in thinking and practice, all of which have been conveyed to each new class of psychiatric residents. As I examine our field, each decade has produced a unique set of practitioners with unique sets of values.

The Shifting Philosophy of American Psychiatry

Prior to World War II, few American medical schools had departments of psychiatry. In many schools they existed as a section in the department of medicine.¹ Treatments at the time were limited. Biologic treatments such as insulin coma and electroshock were used. Psychoanalysis existed in the United States with a number of psychoanalytic institutes but was not significantly engaged in psychiatry. 

This changed after World War II. Psychoanalysis became, in many departments, a critical organizing principle. By 1962, half of all psychiatry departments chairs were psychoanalysts.¹ A competition existed between the neuropsychiatrists of that day and psychoanalytically informed psychiatrists to dominate American psychiatry. For the most part, the analytically informed psychiatrists won.  

In the 1960s and 1970s, an additional non-analytic force arose in American psychiatry: the community psychiatry movement. Community psychiatrists felt that the critical issues that adversely affected mental health were the result of social interactions. As such they believed clinical interacts should be based in the community.

Melvin Sabshin, MD, himself an analyst but also concerned about community and social psychiatry, became medical director of the American Psychiatric Association (from 1974 through 1997). He brokered a truce between all factions that was essentially maintained through the 70s and late 1980s.

By the mid-1990s, psychodynamic or psychoanalytically informed psychiatry receded in importance. Limited numbers of department chairs ware analysts. By 2000, biologic psychiatry reinforced with genomics was overwhelmingly the dominant force in American psychiatry.  

Psychodynamic psychiatry, while still perceived as an important element in understanding behavior, was, by some psychiatrists, relegated to social workers and psychologists. Medications were the primary route for psychiatrists to treat patients. Thomas Insel, director of the National Institute for Mental Health, in describing the psychiatrist of the future s feels they should be neuroscientists.

The Psychiatric Workforce Data derived from the 2013 American Medical Association’s (AMA) annual census of physicians.
Number of General Psychiatrists		37,296
Number of Child and Adolescent Psychiatrists		8,237
Number of Psychiatrists Per Capita (American Medical Association Data and US Census Bureau)
General psychiatry		1 per 8,476
Child and Adolescent Psychiatry		1 per 11,080
Percentage of Practitioner by Sex
Child and Adolescent Psychiatry		1 per 11,080
Percentage of Practitioner by Sex
General Psychiatrists	Male 63.1%	Female 36.9%
Child and Adolescent	Male 49.6%	Female 50.4%
Age of Practitioners
General Psychiatry	Over 55 15,403	Under 55 21,882
Child and Adolescent	Male 49.6%	Female 50.4%
Site of Medical School in Percentage
US Medical Schools	General 65%	Child and Adolescent 65%
International Medical Schools	General 30.2%	Child and Adolescent 29.6%
Percent of Residency Graduates in Practice in Same State Where They Trained
General 56.3%		Child and Adolescent 57.8%
Number of First Year Residents and Fellows
General 1,461	Male 45.8%	Female 54.2%
Child and Adolescent 413	Male 38.9%	Female 61.1%